An overview of intrauterine insemination and ovulation induction

Manual of Intrauterine Insemination and Ovulation Induction, ed. Richard P. Dickey, Peter R. Brinsden and Roman Pyrzak. Published by Cambridge University Press. © Cambridge University Press 2010. (ICI) is to reduce the effect of factors such as vaginal acidity and cervical mucus hostility and to benefit from the deposition of a bolus of prepared motile, morphologically normal sperm as close as possible to the oocytes at the time of ovulation. There continues to be discussion in the literature about whether or not IUI should be complemented by OI – either with the oral medications clomiphene citrate (CC) or tamoxifen (TMX), or with the injectable gonadotropins . Most practitioners are of the opinion that IUI with OI does increase success rates, and many will initially try with CC or TMX, and move on to gonadotropins if there is no success within a few cycles of CC/IUI. The most appropriate time to move on from IUI to IVF is also a matter for debate, but most practitioners agree that the change should be made after no more than 4–6 cycles of IUI (see Chapters 7 and 8). Before proceeding to artificial insemination, couples should undergo a complete assessment, of which a full description is given in Chapters 2 and 3. This includes a thorough medical history, clinical examination and appropriate investigations for any possible causes of a couple’s infertility, such as tubal damage, ovulatory disorder or a male factor. It is essential that couples should receive adequate counseling prior to starting treatment, especially when donor sperm is to be used. Couples should also be assured of complete confidentiality, and informed that all sperm donors are now comprehensively screened for genetic and infective conditions. Couples will wish to know how the donor is to be matched to their own characteristics, the cost of treatment, the probability of success, the potential for complications to occur and the likelihood of their occurrence. Medical professionals and couples can now make use of the internet to find a sperm donor that matches their desired physical, educational, religious and even national and ethnic Introduction Sperm preparation methods developed for in-vitro fertilization and embryo transfer (IVF-ET), such as the wash, swim-up and swim-down techniques, and the use of density gradients, have led to a resurgence of interest in intrauterine insemination (IUI) . The use of washed prepared sperm for IUI has also resulted in a significant reduction in the side effects associated with the use of neat semen for IUI (which never should be used), such as painful uterine cramps, collapse and infection [1,2]. In view of the fact that IUI is a relatively simple procedure compared with in-vitro fertilization (IVF), its popularity as a treatment option for certain diagnostic groups of infertile couples is increasing, since it is intermediate between the simpler ovulation induction (OI) and the more “high tech” IVF. This is particularly so in developing countries, where facilities for IVF may be limited and the cost of treatment by IVF is a major issue. The term “artificial insemination” (AI) covers a range of techniques for insemination: it may be intravaginal, intracervical, intrafallopian, intraperitoneal or intrauterine. AI has been used for many years for a number of different indications, and either the husband/partner’s sperm (AIH) or donor sperm (AID) may be used. It is almost 200 years since John Hunter advised a man with hypospadias to inject his seminal fluid into his wife’s vagina with a syringe, resulting in a normal pregnancy [3]. In the nineteenth century, Sims artificially inseminated six women who had negative postcoital tests. He used their husbands’ semen obtained from the vagina after intercourse; one pregnancy was achieved [4]. The first reported case of human donor insemination was by William Pankhurst from Philadelphia in the United States in 1884 [5]. The rationale for the use of IUI instead of intravaginal insemination (IVI) or intracervical insemination An overview of intrauterine insemination and ovulation induction